Meske DS, Lawal OD, Elder H, et al. Efficacy of opioids versus placebo in chronic pain: a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials. J Pain Res. 2018 May 3;11:923-934. doi: 10.2147/JPR.S160255. eCollection 2018.
Discipline Area Score
Nurse 5 / 7
Physician 5 / 7

Introduction: Opioids have been used for millennia for the treatment of pain. However, the long-term efficacy of opioids to treat chronic non-cancer pain continues to be debated. To evaluate opioids' efficacy in chronic non-cancer pain, we performed a meta-analysis of published clinical trials for µ-opioid receptor agonists performed for US Food and Drug Administration approval.

Methods: MEDLINE and Cochrane trial register were searched for enriched enrollment randomized withdrawal studies (before June 2016). Selection criteria included: adults, =10 subjects per arm, any chronic pain condition, double-blind treatment period lasting =12 weeks, and all µ-agonist opioids approved in the USA.

Results: Fifteen studies met criteria. Opioid efficacy was statistically significant (p<0.001) versus placebo for pain intensity (standardized mean difference: -0.416), =30% and =50% improvement in pain (risk difference: 0.166 and 0.137), patient global impression of change (0.163), and patient global assessment of study medication (0.194). There were minor benefits on physical function and no effect on mental function.

Conclusion: Opioids are efficacious in the treatment of chronic non-cancer pain for up to 3 months in randomized controlled trials. This should be considered, alongside data on opioid safety, in the use of opioids for the treatment of chronic pain.

Comments from MORE raters

Nurse rater

This is an useful Article. As a Rheumatology Nurse Practitioner, I find the results of this study support a common knowledge in the Rheumatology profession. However, with the opioid crises attention, many rheumatologists are shying away from writing opioids as rescue treatment for intermittent arthritis flares in patients with chronic inflammatory arthritis conditions (a waxing and waning disorder). The study findings may ease some of the heartburn of prescribing opioids to patients with inflammatory arthritis conditions who, in my opinion, absolutely may require pain medications for periods up to 12 weeks. During early treatment with DMARDs/Biologics, often pain is persistent until steady state is obtained. Daily function and life ADLs are often affected. Opioids, can safely be used in this arena as this study articulates, although risk/benefit was not addressed.

Nurse rater

For the scope of the topic, the n=15 is quite small.

Nurse rater

I'm not sure the article presented any information I didn't already know.

Nurse rater

See the disclosure at the end of article. Authors are ALL linked to big pharma.

Physician rater

I accept this review but am surprised by the result. My subjective clinical experience of longer term use (quite a bit more than 3 months would be longer term to me) does not entirely support this.

Physician rater

This meta-analysis looked at the efficacy of opioid treatment in any chronic pain state. A total of fifteen published studies met the criteria of double blind randomised studies with more than ten subjects per arm with follow up for twelve or more weeks. The conclusions of the meta-analysis were that chronic opioid treatment was more effective than placebo for treatment of pain with no beneficial effects on physical function and no effect on mental function. While this study supports the use of opioid treatment in the management of chronic non-cancer chronic pain conditions it should be recognized that there is considerable controversy over this topic with studies questioning the long term efficacy of opioid treatment in chronic non-cancer pain and also the benefits of such treatment compared to the side effects from chronic opioid treatment. It is still uncertain with the net long term effects of chronic opioid treatment are positive or negative for patients.
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